Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sierra Vista during CMS and state inspections, most recent first.
A CNA physically restrained a resident with schizophrenia by holding him against a wall during a verbal altercation in a room with a vending machine. The restraint was used despite the resident not posing a danger to himself or others, and this action was not consistent with facility policy, which only allows physical restraint in emergency situations.
The facility failed to maintain food safety and sanitation standards, as observed during a survey. A toaster with food residue was improperly stored, and the floor under the industrial mixer had grime and paint splashes. Additionally, the shelf under the cook's prep area had crusted food, and the Unit 2 kitchen's refrigerator handle and steam table compartment were dirty. The facility's policy requires all food areas to be clean, which was not adhered to.
The facility failed to follow its policies for medication administration, resulting in expired medications being found in the medication carts for two residents. Clozapine and Vitamin B6 tablets were discovered past their expiration dates, contrary to the facility's procedures for removing and disposing of outdated medications. The DON and Pharmacy Consultant confirmed the policy breaches.
The facility failed to secure medications in Unit 2, where a medication room door was not fully closed, and two medication carts were left unlocked and unattended by a PT. This oversight occurred while the PT assisted a resident, leaving medications vulnerable to unauthorized access. The DON confirmed that the facility's policy requires carts to be locked unless in use and under direct observation.
A resident with a dysphagia puree diet order received a meal with visible lumps, contrary to the required smooth texture. The Dietary Supervisor and Registered Dietician confirmed the meal should have been pureed, as per the resident's dietary needs due to missing teeth. The facility's policy on menu preparation was not followed.
The facility failed to maintain the walk-in refrigerator in safe operating condition, with corrosion on the walls and visible expanding foam from a previous repair. The Dietary Supervisor and Registered Dietician confirmed these issues, and the Facility Administrator acknowledged non-compliance with the facility's policy. The FDA Food Code highlights the importance of maintaining equipment to prevent health risks.
A resident with paranoid schizophrenia was abused by a CNA who kicked his leg and threw water on his face after the resident refused to drink water. The incident was witnessed by a Primary Counselor and confirmed by the resident. The facility's Quality Assurance representative recognized the actions as abuse according to the facility's policy.
Improper Use of Physical Restraint by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) physically restrained a resident by placing his arm over the resident's shoulders and holding him against a wall, restricting the resident's movement. The incident took place in a room with a vending machine, where the resident, who had a history of schizophrenia and functional dyspepsia, was found unsupervised. The CNA attempted to escort the resident out after a verbal altercation, during which the resident became agitated and used derogatory language. The CNA's actions escalated to physically restraining the resident, despite the resident not posing an imminent danger to himself or others. Facility records, including the nurse's progress notes and an event summary report, confirmed that the CNA's use of physical restraint was not consistent with facility policy, which only permits such interventions as emergency measures to protect from injury. The administrator acknowledged that the CNA did not follow proper procedures, as the situation did not warrant physical restraint. The facility's policy requires restrictive behavioral interventions to be used only when necessary for safety, which was not the case in this incident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food safety, as observed during a survey. A toaster with an accumulation of food residue was improperly stored in the dry storage area, which was acknowledged by the Dietary Supervisor (DS) as not being in use and needing cleaning. Additionally, the floor under the industrial mixer was found to have black grime, food crumbs, and paint splashes, which the DS attributed to a recent painting job and a missed deep-cleaning session. Further observations revealed that the shelf under the cook's preparation area, which stored clean pans, had crusted food and debris. The DS confirmed that the pans and trays were supposed to be cleaned daily by the cooks. In the Unit 2 kitchen area, the refrigerator door handle had crusted food and smudges, and the compartment under the steam table contained black grime and food debris. The DS acknowledged these conditions as unacceptable and requiring cleaning. The facility's policy and procedure, revised in September 2017, mandates that all food preparation, service, and dining areas be maintained in a clean and sanitary condition. The Registered Dietician (RD) and the Facility Administrator both stated that the expectation was for the kitchen to be cleaned regularly, with no presence of grime or debris. The FDA Federal Food Code sections cited in the report emphasize the importance of keeping food-contact and nonfood-contact surfaces clean to prevent the accumulation of pathogenic microorganisms and to avoid attracting insects or rodents.
Expired Medications Found in Facility's Medication Carts
Penalty
Summary
The facility failed to ensure medications were administered according to its policies and procedures for two residents. For one resident, 11 tablets of Clozapine, a medication used to treat severe mental illness, were found in the medication cart with an expiration date that had passed 124 days prior. The Registered Nurse confirmed the expired status of the medication during an observation and interview. The facility's policy requires that outdated medications be immediately removed from stock and disposed of, which was not followed in this instance. For another resident, five tablets of Vitamin B6, used to treat movement disorders, were found in the medication cart with an expiration date that had passed 8 days prior. A Licensed Vocational Nurse confirmed the expired status of the medication during an observation and interview. The facility's policy mandates that expired medications be marked, stored separately, and destroyed according to the Medication Destruction policy, which was not adhered to. The Director of Nursing acknowledged that the policy was not followed, and the Pharmacy Consultant emphasized that expired medications should not be left in medication carts.
Medication Security Lapse in Unit 2
Penalty
Summary
The facility failed to ensure the secure storage of medications in Unit 2's medication room and on two medication carts. During an observation, it was noted that the medication room door was not fully closed, and both medication carts were left unlocked and unattended by a Psych Tech (PT 1). This lapse in security occurred while PT 1 left the medication room to assist a resident across the hall, leaving the medications vulnerable to unauthorized access. Upon inquiry, PT 1 acknowledged the oversight, stating that the carts should have been locked when unattended to prevent unauthorized access. The Director of Nursing (DON) confirmed that the facility's policy requires medication carts to be locked at all times unless they are in use and under direct observation. The failure to adhere to this policy posed a risk of unauthorized individuals accessing medications, affecting a population of 71 residents.
Failure to Provide Properly Prepared Dysphagia Diet
Penalty
Summary
The facility failed to prepare food in a form designed to meet the needs of a resident with dysphagia, identified as Resident 28. During an observation, it was noted that Resident 28's lunch tray contained chicken potpie and carrots with visible lumps, despite the resident's diet ticket specifying a dysphagia puree diet, which requires a smooth texture. Interviews with the Dietary Supervisor and the Registered Dietician confirmed that the meal should have been pureed to a smooth consistency, as per the resident's dietary order. A review of Resident 28's physician orders and nutritional assessment indicated that a dysphagia puree diet was necessary due to the resident's difficulty with chewing and swallowing, attributed to seven missing teeth. The facility's policy and procedure on menu preparation, which mandates that meals be served as written unless substitutions are necessary, was not adhered to in this instance. The Facility Administrator acknowledged that the staff should have followed the established policy and procedure.
Refrigerator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain equipment in safe operating condition, specifically the walk-in refrigerator in the kitchen. During an observation, corrosion was noted on the bottom walls of the refrigerator, and yellow expanding foam was visible from behind the posterior wall. The Dietary Supervisor acknowledged that the foam was from a previous maintenance repair and should not have been visible, and that there should not be corrosion on the walls. The Registered Dietician also confirmed that the refrigerator should not have had corrosion or visible expanding foam from repair. The facility's policy and procedure, revised in September 2017, stated that all foodservice equipment should be clean, sanitary, and in proper working order, and all non-food contact equipment should be clean and free of debris. However, the Facility Administrator admitted that the facility did not follow this policy. Additionally, the FDA Federal Food Code, section 4-501.11, emphasized the importance of maintaining equipment in good repair to ensure proper operation and prevent health risks. The failure to maintain the refrigerator in proper condition had the potential to result in unsafe temperature control for safety foods and the accumulation of bacterial growth.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a Certified Nursing Assistant (CNA) threw water on the resident's face and kicked his right leg. This incident was witnessed by a Primary Counselor who reported that the resident, diagnosed with paranoid schizophrenia, refused to drink water after taking his medication. The CNA reacted to the resident's sudden movement by kicking him and pouring water on his face. The resident confirmed the incident during an interview, indicating the location of the kick on his right lower leg. The facility's Quality Assurance representative acknowledged that the CNA's actions constituted abuse, as defined by the facility's Abuse Prohibition policy. The policy, reviewed during the investigation, includes physical abuse such as hitting, slapping, pinching, and kicking. The resident's cognitive function was assessed as normal, with a score of 15/15 on the BIMS assessment, suggesting that he required minimal cognitive aid and memory support from staff.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Highland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Del Rosa Villa | 1.1 mi | — | 13 | 0 |
| Highland Palms Healthcare Center | 1.7 mi | — | 9 | 0 |
| Haven Post Acute | 1.8 mi | — | 1 | 0 |
| Waterman Canyon Post Acute | 2.9 mi | — | 2 | 0 |
| Valley Healthcare Center | 2.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.